Gas Mileage Reimbursement Form

July 8, 2011

A gas mileage reimbursement form helps in recovering the expenses incurred for travel from one place to another. The reimbursement being claimed has to be supported with necessary travel receipts wherever possible along with parking receipts if any. The reimbursement of gas mileage is permitted according to the approved rate per mile assigned by the concerned authorities which is subject to change from time to time. After having received the gas mileage reimbursement form the credit is usually given within a period of five to seven business days.

Sample Gas mileage reimbursement form

Name of the applicant                                                    __________________________

Personal id number                                                        __________________________

Complete mailing address                                             __________________________

Contact number                                                             __________________________

Email id                                                                         __________________________

Age as per driving license                                           __________________________

Date of birth                                                                 __________________________


Male                                                                              __________________________

Female                                                                          __________________________

Driving License Number                                              ___________________________

Type of Vehicle                                                            __________________________

Number of miles traveled (daily sheet)                         __________________________

Vehicle Mileage                                                           __________________________

Rate per mile                                                                __________________________

Travel Log (attachment of actual miles traveled)         __________________________

Purpose of Travel:-

Business visit                                                               __________________________

Personal visit                                                                __________________________

Parking receipts (if any)                                               ___________________________

Total miles traveled                                                    ___________________________

Total amount incurred                                                 __________________________

Period of travel                                                            __________________________

Starting destination                                                      __________________________

Ending destination                                                      __________________________

Vehicle meter reading at start of travel (daily)            __________________________

Vehicle meter reading at end of travel (daily)             __________________________

Signature of Applicant                                                __________________________

Date of application                                                      __________________________

Approver Signature                                                     __________________________

Payment release date                                                   ___________________________


Download Gas Mileage Reimbursement Form in Word Format

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